Showing papers by "Stefano Siboni published in 2010"

Covered nitinol stents for the treatment of esophageal strictures and leaks

Abstract: AIM: To compare 2 different types of covered esophageal nitinol stents (Ultraflex and Choostent) in terms of efficacy, complications, and long-term outcome. METHODS: A retrospective review of a consecutive series of 65 patients who underwent endoscopic placement of an Ultraflex stent (n = 33) or a Choostent (n = 32) from June 2001 to October 2009 was conducted. RESULTS: Stent placement was successful in all patients without hospital mortality. No significant differences in patient discomfort and complications were observed between the Ultraflex stent and Choostent groups. The median follow-up time was 6 mo (inter-quartile range 3-16 mo). Endoscopic reintervention was required in 9 patients (14%) because of stent migration or food obstruction. No significant difference in the rate of reintervention between the 2 groups was observed (P = 0.8). The mean dysphagia score 1 mo after stent placement was 1.9 ± 0.3 for the Ultraflex stent and 2.1 ± 0.4 for the Choostent (P = 0.6). At 1-mo follow-up endoscopy, the cover membrane of the stent appeared to be damaged more frequently in the Choostent group (P = 0.34). Removal of the Choostent was possible up to 8 wk without difficulty. CONCLUSION: Ultraflex and Choostent proved to be equally reliable for palliation of dysphagia and leaks. Removal of the Choostent was easy and safe under mild sedation.

Tension pneumoperitoneum following endoscopic submucosal dissection of leiomyoma of the cardia.

Abstract: esophagography with barium because of persistent heartburn and regurgitation. A smooth defect with eccentric contours, about 2 × 3 cm in size, was found at the esophagogastric junction. Upper gastrointestinal endoscopy confirmed the presence of a soft, polypoid, submucosal mass surrounding the cardia. Endoscopic ultrasonography showed a hypoechogenic, Cshaped lesion originating from the muscularis propria, with a fine echotexture consistent with leiomyoma. No biopsy was taken. The patient was considered a good candidate for endoscopic submucosal resection. The procedure was performed under general anesthesia with the patient in the supine position. A standard 9-mm endoscope with a soft transparent hood attached to its tip was advanced through an overtube into the stomach and then retroflexed. Enucleation was carried out after submucosal injection of 10mL of diluted epinephrine using an insulated tip diathermic electrosurgical knife (IT-Knife 2; Olympus, Tokyo, Japan) at 100W and a hook knife (Olympus Optical, Tokyo, Japan) at 60W. The dissection started along the lower border of the lesion and then extended circumferentially. Once the submucosal layer was reached, the tumor was gradually dissected away from the muscular layer and removed with an endoscopic bag. En bloc resection was achieved and the mucosal margins were sutured using three endoscopic clips. The procedure lasted 170 minutes. Histological examination confirmed the diagnosis of leiomyoma. Postoperatively, the patient complained of severe, persistent abdominal pain unrelieved by analgesics and nasogastric intubation. Physical examination revealed generalized distension and tenderness of the abdomen, tachycardia, andmild hypotension. A plain film of the abdomen showed free air in the peritoneal cavity probably related to an air leak through the intact gastric wall (●\" Fig. 1). Paracentesis was performed for decompression using a 20-gauge needle catheter. The patient recovered uneventfully after aspiration of about 3 L of air from the peritoneal cavity, and was discharged on postoperative day 3. Endoscopic submucosal enucleation of tumors of the esophagogastric junction is a safe and effective technique in experienced hands. Overt perforation can occur, mainly on the gastric side, and can be managed by immediate clip application [1]. To our knowledge, this is the first reported case of tension pneumoperitoneum occurring after endoscopic submucosal dissection for leiomyoma at the esophagogastric junction. No definite perforation was recognized in our patient during the procedure, but severe symptoms developed in the postoperative period, requiring decompression paracentesis for relief. Interestingly, Fu et al. [2] described a similar complication during endoscopic submucosal dissection for adenoma of the cecum and the transverse colon. The procedure was discontinued, and an emergency abdominal computed tomography showed a large pneumoperitoneum with collapse of the inferior vena cava. The patient’s symptoms were effectively relieved by paracentesis, and the blood pressure and diameter of the inferior vena cava returned to normal immediately after decompression. In conclusion, tension pneumoperitoneum is a rare but potential complication of endoscopic submucosal dissection at the esophagogastric junction. Even in the absence of endoscopically detected perforation, prompt recognition and treatment of pneumoperitoneum ismandatory to prevent the cascade of events leading to cardiopulmonary complications and the abdominal compartment syndrome.

Proposal of a Punch Biopsy Protocol as a Pre-requisite for the Establishment of a Tissue Bank from Resected Esophageal Tumors

Abstract: With the development of tissue banking, a need for homogeneous methods of collection, processing, and storage of tissue has emerged. We describe the implementation of a biological bank in a high-volume, tertiary care University referral center for esophageal cancer surgery. We also propose an original punch biopsy technique of the surgical specimen. The method proved to be simple, reproducible, and not expensive. Unified standards for specimen collection are necessary to improve results of specimen-based diagnostic testing and research in surgical oncology.